MEDICARE: JACQUELINE DIONE KENTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	188379	GA

General Provider Information

NPI Number	:	1174485882
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE DIONE KENTON

Provider Business Mailing Address
First Line	:	524 COVENTRY WAY
Second Line	:
City	:	MCDONOUGH
State	:	GA
Zip	:	30252-3627
Country	:	US
Telephone Number	:	347-752-8197
Fax Number	:

Provider Business Practice Location Address
First Line	:	524 COVENTRY WAY
Second Line	:
City	:	MCDONOUGH
State	:	GA
Zip	:	30252-3627
Country	:	US
Telephone Number	:	347-752-8197
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2025
Last Update Date	:	12/01/2025

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